Provider Demographics
NPI:1346509221
Name:PERDUE, TARA (PA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PERDUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:JEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:913 N DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2503
Mailing Address - Country:US
Mailing Address - Phone:877-783-6257
Mailing Address - Fax:859-514-5521
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:877-783-6257
Practice Address - Fax:859-514-5521
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003403363AM0700X
OH50003403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086921Medicaid
KY7100353530Medicaid
OHH226822Medicare PIN
KY7100353530Medicaid